Blog – The cry resounds: 'Go physician-led team'

Go team! Or, more accurately, “Go physician-led team” was one of the battle cries of the American Medical Association House of Delegates interim meeting.

But what if there are no physicians around to lead the team? Would the AMA be willing to call for a draft where doctors are pulled from comfortable suburban practices and dragged to the rural hinterlands like a professional athlete picked by a new team in an expansion draft?

OK. No more sports analogies. But there is a definite trend of physicians calling for physician-led teams without addressing the realities of the projected physician shortage and the existing “maldistribution” of doctors.

“The future of healthcare delivery is patient-centered and will require a team approach, and physicians and healthcare professionals need to be prepared to efficiently work together to provide quality patient care,” said AMA board member Dr. Carl Sirio in a news release.

In a speech to delegates, AMA President Dr. Jeremy Lazarus cited how physicians are leading the Southcentral Foundation, a healthcare team in Anchorage, Alaska, “run by and for Alaska Natives.” The team there consists of doctors, nurses, medical assistants and “traditional healers.”

Interestingly, according to a Dartmouth Atlas report (PDF) using 2006 data, Anchorage is one of the few areas in the country with more than 100 primary-care physicians per 100,000 residents. With 100.5 primary-care doctors per 100,000 residents, Anchorage trails only San Francisco (117); Lebanon, N.H. (105.5); Washington (102); and White Plains, N.Y. (101.5). So, even though it's a far-off land, Anchorage residents apparently are never that far from a primary-care physician, and so it is an outlier and not representative of most rural or isolated areas where doctors are few and far between.

Given “the imminent coverage of up to 30 million more Americans starting in 2014 and existing and predicted shortages of physicians and nurses, support for physician-led team-based care is building,” said the AMA release. While support for team-based care such as the patient-centered medical home and accountable care organization models may be building, support for these teams to be physician led is coming mostly from physicians.

Organizations that recognize practices as medical homes, such as the National Committee for Quality Assurance, Accreditation Association for Ambulatory Health Care and the Joint Commission, are not requiring physician leadership in their certification criteria.

After the AAFP issued its paper, titled “Primary Care for the 21st Century, Ensuring a Quality, Physician-led Team for Every Patient,” it was immediately slammed by the American Academy of Nurse Practitioners as “misdirected and out of step.”

In an interview, nurse practitioner Sean Lyon, whose physician-less practice in New London, N.H., has been recognized as a medical home by the NCQA, mocked a chapter in the AAFP report titled “Our Primary Care System is Changing.”

“The irony is that they're not changing with it,” Lyon told me.

While nurses and nurse practitioners may have their own reasons for disagreeing, if the AMA, AAFP and other physician organizations continue to issue proclamations about physician-led teams, they'll have to include contingency plans for how this applies to areas with few physicians.

The AAFP's report notes that, since 2006, the organization has been advocating for training and education policies that will help reverse the projected physician workforce shortage.

Expanding the number of residency positions is one obvious step in the right direction, but Washington has failed to address the issue. In fact, it seems to be a distant third behind tort reform and Medicare payment stability among physician issues that politicians are unwilling to resolve.

The point here is that waiting for Washington to solve the problem is not a viable option. Telephone or electronic consults could help, but being told what to do by someone who is unwilling to relocate to your location would grow wearisome I imagine. A rotating cast of temporary doctors overseeing a permanent staff would create the same problem as well as appearing to run contrary to the goal of reducing the fragmentation of care delivery.

I don't disagree with the calls for physician-led teams. But those calls need to be coupled with ideas on how this is done in areas where physicians don't want to practice.